Gournay: Places of healing or torment

Since the early 1990s, I have been involved in a large number of initiatives designed to improve psychiatric patient care in the UK and I have authored numerous articles and reports on the subject. But my frustration has grown because while these reports now amount to a fair sized library, inpatient psychiatric wards seem, to me, to be becoming more dangerous for both patients and staff, more unsanitary and certainly much less therapeutic.

Tonight's Dispatches film on Channel 4 provides a graphic account of care in three average NHS Trusts - the programme-makers took great care to ensure that they did not select Trusts with a particularly good or bad record. The images contained in this undercover investigation are both disturbing and thought-provoking: from female patients claiming to have been sexually assaulted, patients self-harming with objects found on the ward and overstretched staff threatening patients and illegally administering medication.

Over the past decade mental health care has been increasingly delivered in community settings. As a result, around 20,000 patients in our wards comprise the sickest and, in many cases, the most dangerous individuals in our healthcare system. Thirty to 50 per cent of patients admitted to hospitals have drug or alcohol problems in addition to their mental illness; this makes these patients much less likely to comply with treatment, to be more disturbed and require care delivered with a high level of skill, by a workforce of suitable size.

Although the vast majority of nurses and doctors in mental health care are dedicated people, doing their very best in an often intolerable and under resourced system, Dispatches reveals the wide range of issues of concern. The most important of these is the ultimate tragedy - the loss of life by suicide.

Of the 5,000 or so suicides that occur in the UK every year, nearly 200 of these are by psychiatric inpatients - all the more devastating for their families because their admission to hospital was meant to protect them. The Government's own confidential Inquiry into suicides and homicides by mentally ill people admit that many of these suicides are preventable. While there has been a modest reduction in inpatient suicide rates in the past five years, patients are still dying needlessly.

In the film, the undercover reporter who is working as a healthcare assistant found a patient was able to abscond twice from her ward - a patient who had expressed every intention of throwing herself in front of a train. She also discovered plastic bags in lockable toilets on a ward where a patient had threatened to suffocate himself using a bag. Despite raising her concerns to staff no action was taken. Most distressing of all, a patient who had admitted having suicidal thoughts was left in an empty dormitory on her own for 20 minutes - allowing her to hang herself from a curtain rail. Fortunately she survived but was too close a near miss.

Although we have known for many years that hanging is the most common method, some NHS Trusts are still not taking sufficient steps to remove obvious ligature points in ward areas. In many cases, suicidal patients have been allowed access to ligatures - such as belts. In addition to suicides, there are many more cases where patients needlessly suffer serious self-harm, often resulting in permanent disability. In the Dispatches film - the reporter discovered a patient who had cut her wrists with a rusty razor blade. When she alerted her colleagues a senior member of staff replied: "If she wants to do it, she'll do it." The causes of these tragedies boil down to the under-resourcing of wards, both in staff numbers and training and the consequent inability of demoralized staff to implement preventative measures.

Many of the patients in our wards are vulnerable women. The NHS National Patient Safety Agency recently published a report - after some considerable pressure from Mental Health lobby groups - which revealed an alarming number of reported rapes and serious sexual assaults. In the film, the reporter hears disturbing claims of sexual harassment and assault from female patients. At the heart of this problem is the Government's inability to implement numerous promises that women should be protected within single sex environments. Whilst it is important, for men and women to share activities in the various therapy groups, many wards still offer little or no protection to vulnerable females who, ironically, are often suffering from mental illnesses caused by sexual abuse.

The ward environments in general are counter-therapeutic because, not only are men and women mixing in unacceptable ways, but most wards are overcrowded, some do not have access to fresh air or natural light, and they are often in a dilapidated condition. Many wards, both in the programme and in my general experience, are simply filthy. Indeed, some of the accommodation I have seen, reminds me of the "doss houses" of the 1960s and 1970s.

Of gravest concern though, is the failure on many wards to prevent violent patients from attacking staff and other patients. As someone who has led two recent initiatives on violence in mental health care, I remain appalled that we are still operating our wards with many staff who have received little or no training in the prevention or management of violence. This deficit, of course, exacerbates an already dangerous situation and, over the years, we have numerous accounts of patients and staff who have died, or suffered serious injury, as a result of violence that probably, could have been prevented.

The Dispatches film examines the death of Eshan Chattun a healthcare assistant who was beaten to death by a psychiatric patient who was known to be violent. Eshan had been supervising him on his own and he died because he had no way of summoning help because he was not given a personal alarm. The undercover reporter who worked on a hospital run by the same Trust found staff didn't have enough alarms to go round. One night a female member of staff was attacked by a patient - luckily for her, other members of staff were close enough to hear her screams.

I believe that there are three key reasons why all these problems have been allowed to continue without radical action being taken.

First, despite the rhetoric of Government policy, which states that mental health is a priority, the reality is that, in terms of the resources allocated, it remains a Cinderella service. All of the fine words written by civil servants and report writers, such as myself, over the years, do not replace real investment of new money. So often I have listened to announcements of £X million being allocated to improve various aspect of service. In the end, you find out that the £X million will not come until the year after next, and when it does come, it will be siphoned from another hard-pressed area.

The second reason why these issues are not recognized is that a very large amount of sub-standard care is hidden when Trusts quietly settle legal actions by paying damages on the basis of admitting no fault. The reason for this is obvious to all; there is no defence to be offered for the, at times, appalling negligence.

The final reason why these issues remain low key in our perception is that most people view mental illness as something that happens to other people. The public are wrong. Any of us could develop a mental illness such as severe depression and need hospital admission.

As a mental health professional, I have to ask a simple question: If I, or someone I loved, needed to be admitted to one of our inpatient wards, would I agree to admission? My answer to that question is obvious.

Kevin Gournay is Emeritus Professor at the Institute of Psychiatry, Kings College, London

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